Intake Form (Rev 9/11/2006)
1. Name _______________________________ Birth Date ___________________
2. SS# ___________________________ Ethnicity _________ Hispanic _______
4. Marital Status _____________ Referral _______________________________
5. Emergency Contact Name __________________________________________
County____________________ State ______________
6. Relation _________________ Phone # _________________________________
7. Do you have any children? _______ Who has custody? _______________
8. Are you employed? _______ Do you have any other income? _________
9. Are you a veteran? _______ What type of discharge? _________________
10. Do you receive benefits? ___________________________________________
11. Are you a resident of Charlotte County? _______ How long? __________
12. Are you homeless? ________ How many times? ______________________
13. Were you institutionalized prior to 18 yrs. of age? ___________________
14. Do you have any disabilities? ______________________________________
15. Any infectious diseases? __________________________________________
16. What is your level of education? ____________________________________
17. Do you have a drivers license? _______ Transportation? _____________
18. Are you a U.S. citizen? ______ Have you tried AA before? ____________
19. Do you have a relative, spouse or friend residing with Mission Unity,
Inc. (Past or Present?) ______________________________________________